Despite costs, EMRs boost efficiency and productivity

In the constant search for ways to help physicians operate their practices more efficiently, perhaps nothing causes more controversy than the electronic medical record.

Some doctors see it as a way to better manage patient care, while others shun it as a tool for mining data and unfairly judging physicians based on information that is not completely quantifiable.

While EMRs still have a long way to go toward standard use, Rochester practices are in the 60 percent range in terms of adoption, says Nancy Adams, executive director of the Monroe County Medical Society.

"Rochester is ahead of the curve," she says.

Careful planning and significant community investment helped the area get that head start, Adams says. The business community and the Greater Rochester Health Foundation had the critical startup funding ready in 2005 to obtain $5 million in state grants to create a health information exchange. In 2006, the Rochester Regional Health Information Organization was incorporated.

The RHIO provides electronic exchange of lab and imaging results for doctors' offices. It is working to package information about patients in a more standard way to support referrals among doctors. The organization recently added a portal where patients can register their consent preferences by uploading directives for when they are incapacitated due to illness or injury. Providers with or without electronic systems can access the RHIO.

"Being early adopters, we're fortunate to be over the hurdles," Adams says. "We're not facing the problems others like Syracuse are now."

One of those obstacles is an interface problem. Adams says different practices and hospitals using electronic medical records from different vendors could not talk to each other.

"We had to start limiting vendors we would work with. We have 20 to 30 EMR vendors now. Syracuse has over 100. The complexities they have are much greater," Adams says. "It's good we got ahead of the game."

Epic Systems Corp. is a prominent EMR vendor in Rochester, Adams says, serving the University of Rochester Medical Center and Rochester General Hospital. NextGen Healthcare Information Systems LLC is another one, with Unity Health System as a large customer. Other big EMR players here include Medent, eClinicalWorks and Allscripts.

When a physician's practice converts to using electronic records, the transition brings an entirely new way of doing business.

"Tremendous change needs to happen with work flow. Typically, productivity goes down for six months. The physician can't see as many patients, so revenues go down," Adams explains. "It takes some time to get up to speed, and some physicians don't even know how to type. So we've added some keyboarding classes to help them."

Even with the help physicians get in adjusting to the use of electronic records, the largest barrier to adopting EMR systems may be the cost, Adams says. On average, initial implementation costs between $27,000 and $60,000, and that does not include upgrades to the system once it is installed.

"There certainly are costs," says Leslie Algase M.D., a physician at Partners in Internal Medicine. "There are monthly maintenance costs, and each time you add an item such as an EKG machine, you have to buy a modem. There are some things we have chosen not to add because of the cost."

Algase's practice converted to EMRs in 2010 with a New York State Health Care Efficiency and Affordability Law grant. She says EMRs have been a significant investment but notes that using paper has costs as well. In fact, her office has been able to eliminate one secretarial position since implementing the EMR system because there is less paperwork filing.

"So with that, there is less overhead and it is almost a wash," Algase says.

Making the conversion to electronic records was not easy, despite the training the Medical Society provided for her practice, she admits. But even with the additional work to meet the guidelines set forth two months later by the federal government's "meaningful use" mandate, Algase says, the conversion has been well worth the pain and the cost.

"I think we've been glad all along," she says. "There are good things and bad things, but I do think we practice more efficiently."

One of the biggest benefits of the EMR system is the way it helps Algase manage her patients with chronic illnesses.

"It helps to keep track of patient compliance. You don't have to think of everything on your own," Algase explains. "Patients with diabetes, heart disease, high cholesterol-who need to be on certain medications or need blood tests, eye exams-the computer will let you know if they haven't had these things done."

EMRs have dramatically improved the way Louis Papa M.D. runs his practice. He believes EMRs help physicians capture more information than ever before, which ultimately benefits the patient.

"There is a lot to the 'sticky note' factor we took for granted. We can make better documentation now," Papa says.

His practice, Olsan Medical Group, adopted EMRs in 2006. Papa says he is fortunate that his practice can afford the expense of adding voice recognition to the system: He dictates his notes instead of typing them. This allows him to create patient notes in a more conversational format, he says.

Papa, however, does find the layout of the EMR screen to be a problem.

"There is a lot of cluttering of the screen, redundancy," he says. "It's not tailored to everyone using it. We shouldn't have to see all the insurance information just for a prescription. It shouldn't have to be a treasure hunt."

Still, the ways in which EMRs have made Papa's work easier are important.

"So much in medicine is data management, and it's easier with EMRs to have things formatted. They're legible, searchable and you can find things much quicker," he says.

Papa says there is less "dead time" waiting for reports to print so they can be read and analyzed. This means faster diagnosis and treatment for patients. And with electronic prescriptions, there are cross-checks that alert physicians and pharmacists to any possible interactions with other medications. But that can be a problem as well, Papa says.

"More than half the time, warnings pop up ... and they are erroneous dangers," he says. "So we don't pay attention, and this could lead to alarm fatigue. That could be dangerous if things aren't taken seriously."

Some local physicians believe EMRs pose more problems than they solve. James Gaden, a physician for 21 years with a solo practice in Kendall, refuses to adopt electronic records, at least for the present.

"As a small practice, you don't have the pull to get the tech support as fast as you need it, the way the bigger guys like Strong can," Gaden says. "And the cost just to get set up is $25,000 to $60,000 per physician. Then there's training on top of that."

One of the main problems Gaden sees is the lack of interoperability between EMR systems.

"We need a centralized repository system of data. I should be able to go there and look at lab work, cardiology notes, images. There should be a standard style like there is when I submit an article to a medical journal," Gaden explains. "But Epic has its own style. Many do."

Gaden sees other disadvantages with EMRs, such as privacy concerns with patient files being stored electronically.

"Information is stored on the cloud where people can hack in and steal whatever they want," he says. "Until we can find a way to keep people from getting what they shouldn't, I'm not ready to jump."

One of Gaden's main concerns is how the data doctors enter in the system could be used. He believes doctors could be evaluated based on patient compliance in the same way teachers are evaluated on their performance based on student test scores.

"The data is skewed towards the patients I always see. If I have 5,000 patients I probably never see half of them. There's a few that come in once a year, then a handful that come as they need to, then there are those, about a dozen, who are here all the time," Gaden explains. "They have COPD, diabetes. So all of my data would be populated on them. But I can't stamp out chronic illness."

As the issues with EMRs are identified and addressed, Gaden says, the systems will get better.

"This will work, but it's not ready yet for prime time," he says. "EMRs were rolled out and doctors were pressured into using them before they were thought through."